Cardiovascular Physiology Heart Sounds Murmurs Dr Abeer A

Cardiovascular Physiology Heart Sounds & Murmurs Dr. Abeer A. Al-Masri MBBS, MSc, Ph. D Associate Professor Consultant Cardiovascular Physiologist Faculty of Medicine, KSU

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Detected over anterior chest wall by: ■ Auscultation: … (Stethoscope) ■ Phonocardiography: (sound recording device) Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU 3

Best heard at 4 certain areas: ■ Pulmonary area: • ■ 5 nd Lt intercostal space crossing midclavicular line, or • 9 cm (2. 5 -3 in) from sternum • 2 nd Lt intercostal space ■ Aortic area: • 2 nd Rt costal cartilage Mitral area: ■ Tricuspid area: • Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU lower part of sternum towards Rt side 4

Heart Sounds: ‘ 4’ heart sounds can be detected: ■ 1 st & 2 nd ht sounds … (usually audible) ■ 3 rd & 4 th ht sounds … (sometimes detected) Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU 5

Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU 6

Due to closure of the AV- vs. It marks beginning of ventricular systole. Recorded at the beginning of the ‘isometric contraction’ phase. Long in duration ( 0. 15 sec. ) Of low pitch (LUB). . (Loud) 25 -35 Hz. Best heard at Mitral & Tricuspid areas. Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU 7

Due to closure of semilunar- vs. Marks the beginning of ventricular diastole. Recorded at the beginning of the ‘isometric relaxation’ phase. Short in duration ( Of high pitch (DUB). . 50 Hz. 0. 11 -0. 125 (Soft & sec. ) Sharp) Best heard at Aortic & Pulmonary areas. Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU 8

S 2 splits physiologically into 2 sounds duringinspiration = Physiological Splitting Physiological splitting during INSPIRATION This splitting occurs due to delay closure of pulmonary valve Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU 9

Recorded during the ‘rapid filling’ phase, due to rush of blood into the ventricle. Duration 0. 05 sec. S 3 is usually not audible. . (very low pitch) ? heard in children. Best heard at Mitral area. Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU 10

§ Recorded during ‘atrial systole. ’ § § Duration 0. 04 sec. S 4 is usually not audible. . (very low pitch) ? heard in elderly. Best heard at Mitral area. Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU 11

Important for diagnosis of heart murmurs. Abnormal extra heart sounds heard during the heart beat cycle. Produced by turbulence (abnormal patterns) of blood flow through the heart & its valves. Murmurs are longer than heart sounds. Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU 12

q Valves closing: § Atrio-ventricular = (S 1) § Semilunar = (S 2) q Increased intra-cardiac hemodynamics (Murmurs): q Blood striking the left ventricle = (S 3, S 4) q Increased flow across normal valves. q Turbulent flow through an abnormalvalve. q Turbulent flow through septal defect. Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU 13

1. Physiological Murmurs: - blood flow across normal valves: e. g. - Pregnancy - Hyperthyroidism - Anemia - Fever - Children Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU 2. Pathological Murmurs: - Turbulent flow through abnormal valves, or septal defect. . ? Congenital e. g. - Tight valve (stenosis) - Leaky valve (regurgitation or insufficiency) 14

q Timing (systolic or diastolic) q Shape q Location q Radiation q Intensity q Pitch q Quality Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU 15

Murmurs are described according to their position in the cardiac cycle: § Systolic. § Diastolic. § Continuous. Holosystolic Murmur Diastolic Murmur Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU 16

Diastolic Murmurs • Between S 2 & S 1 • Classified as early, mid, late Systolic Murmurs • Between S 1 & S 2 • Classified as early, mid, late, holosystolic Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU 17

§ § Crescendo (grows louder. ) Decrescendo. Crescendo-decrescendo (Diamond-shaped. ) Plateau. Murmurs described according to the waxing & waning of the sound Diamond-shaped Murmur Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU 18

3. Location of maximum intensity Determined by the site where the murmur originates; e. g. Aortic, Pulmonary, Tricuspid, & Mitral listening areas. 4. Radiation Reflects intensity of the murmur & direction of blood flow. Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU 19

§ Graded on a (6) point according to Levine scale: Classification of murmurs by loudness Grade 1 • Lowest intensity • Very faint Grade 2 Grade 3 Grade 4 Grade 5 Grade 6 • Low • Loudest • Medium • Loud • Medium intensity intensity • Quiet but • Moderately • Loud • Heard with • No heard stethoscope loud • Thrills immediately partly off needed • Thrills the chest Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU • Thrills 20

I / VI need quiet room and trained ear to hear. (difficult to hear even by expert listeners) II / VI audible to anyone who listens attentively (usually audible by all listeners) III / VI loud, but not palpable (easy to hear even by inexperienced listeners, but without a palpable thrill) IV / VI loud and palpable: it produces a precordial thrill VI / VI audible without a stethoscope audible with your stethoscope placed perpendicular to chest wall Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU 21

6. Pitch High, medium, low. 7. Quality Blowing, harsh, rumbling & musical. 8. Others: i. Variation with respiration: Right sided murmurs change > left sided. ii. Variation with position of patient. iii. Variation with special maneuvers: Valsalva Murmurs in length & intensity. Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU 22

Systolic Murmurs Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU

q Derived from harsh & turbulence in flow. q Associated with: 1. flow across normal valve. 2. flow into a dilated great vessel. 3. flow across an abnormal valve, or narrowed ventricular outflow tract - e. g. aortic /pulmonary stenosis. 4. flow across an incompetent AV valve - e. g. mitral/tricuspid regurgitation. 5. flow across the inter-ventricular septum - e. g. VSD. Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU 24

1. Aortic stenosis – ejection murmur. 2. Pulmonary stenosis – ejection murmur + spilling S 2. 3. Mitral / Tricuspid regurgitation – holosystolic. 4. Mitral valve prolapse – mid-late systole. 5. Ventricular septal defect (VSD) – holosystolic. S 1 Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU S 2 S 1 25

q Most common kind of heart murmur. q Usually crescendo-decrescendo. q They ? may be: 1. Innocent Common in children & young adults. 2. Physiological Can be detected in hyper-dynamicstates, e. g. anemia, pregnancy, fever & hyperthyroidism. 3. Pathological Secondary to structural CV abnormalities, e. g. Aortic/pulmonary stenosis, Hypertrophic cardiomyopathy & mitral prolapse. Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU 26

q Pathological murmur. q Begins immediately with S 1 & continues up to S 2. q Heard with: § Mitral/tricuspid regurgitation. § Ventricular septal defect (VSD). Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU 27

Narrowing of aortic outflow tract causing obstruction of flow from LV into ascending aorta T- mid-systolic (ejection) murmur. Ø L- best heard @ aortic area, radiates Ø along carotid arteries. S 1 S 2 C- harsh, loud, may have associated thrill, “ejection click. ” Ø A- older age, bicuspid aortic valve, rheumatic fever. Ø Note: T- Timing; L- Location; C- Character; A- Association Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU 28

Bulging of one or both mitral valve leaflets into LA during LV systole T- mid- late systolic murmur. Ø L- best heard @ apex. S 1 S 2 Ø C- mid systolic click. Ø A- ~5% normal population, asymptomatic, ? sudden death. Ø Note: T- Timing; L- Location; C- Character; A- Association Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU 29

Retrograde flow from LV into LA through an incompetent mitral valve T- holosystolic murmur. Ø L- best heard @ apex, radiates to left axilla. S 1 Ø C- soft, high-pitched, blowing. Ø A- MV prolapse, MV myxomatous degeneration, MI, rheumatic heart disease, cardiomyopathy, endocarditis. Ø S 2 Note: T- Timing; L- Location; C- Character; A- Association Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU 30

Diastolic Murmurs Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU

q Almost always indicate heart disease. q Two basic types: 1. Early decrescendo diastolic murmurs: Signify regurgitant flow through an incompetent semilunar valve, e. g. aortic/pulmonary regurgitation. 2. Rumbling diastolic murmurs in mid- or late diastole: Suggest stenosis of an AV valve, e. g. mitral/tricuspid stenosis. Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU 32

Soft, blowing, gurgle 1. Aortic regurgitation - early diastole 2. Mitral stenosis - mid to late (pre-systolic)diastole S 1 Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU S 2 S 1 33

Retrograde flow from aorta into LV through incompetent aortic cusps Ø Ø T- diastolic (early) murmur. L- best heard @2 nd-4 th left intercostal spaces. S 1 S 2 C- high-pitched, blowing, decrescendo. A- aortic root degeneration, rheumatic heart disease, VSD w/aortic valve prolapse (kids. ) S 1 Note: T- Timing; L- Location; C- Character; A- Association Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU 34

Obstruction of flow from LA to LV because of a narrowed mitral orifice (Valve becomes thickened & calcified) T- diastolic (mid-diastolic, or pre-systolic) murmur with ‘opening snap’ after closure of aortic valve. Ø L- best heard @ apex. Ø C- low pitched (heard with bell. ) Ø A- rheumatic fever. Ø S 1 S 2 S 1 Note: T- Timing; L- Location; C- Character; A- Association Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU 35

S 1 S 2 OS Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU S 1 36

Continuous Murmurs Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU

q Begin in systole, ? peak near S 2 & continue into all or part of diastole. q Heard with: § Patent ductus arteriosus (PDA) § Ventricular septal defect (VSD) Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU 38

1. Patent ductus arteriosus (PDA) 2. ? Ventricular septal defect (VSD) S 1 Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU S 2 S 1 39

Failure of closure of the duct between pulmonary artery & aorta T- continuous murmur. Ø L- best heard @ upper left sternal border. S 1 Ø C- machine-like. Ø A- left to right shunt, cyanosis. Ø S 2 S 1 Note: T- Timing; L- Location; C- Character; A- Association Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU 40

Patent Ductus Arteriosus with Resultant Left-to-Right Shunting Dr. Abeer A. Al-Masri, Faculty of Medicine, KSU 41

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